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Proteorhodopsin (PR) is a microbial proton pump that plays a significant role in phototrophy of bacteria in marine environments. Fundamental understanding of the structure-function relationship that drives proton pumping in PR has largely been elusive due to a lack of high-resolution structures of the photointermediates in the PR photocycle. Extending upon previous work, we used long-time scale molecular dynamics (MD) simulations to characterize the M state of the blue variant of PR, which represents the first proton transfer that takes place in the photocycle. Several notable structural changes occur in the M state that are hallmarks of subsequent steps in the PR photocycle, indicating that although this protein is often compared to the canonical microbial rhodopsins, such as bacteriorhodopsin, PR possesses characteristics that make it distinct among the rapidly increasing and widely variable catalog of microbial rhodopsins.

Objectives: Pediatric epistaxis is a common, often non-operative condition encountered by Otolaryngologists. The present study seeks to (1) describe our outcomes of epistaxis management, (2) estimate the associated healthcare burden, and (3) propose a clinical model to optimize care coordination with primary care and advanced practice providers., Methods: Retrospective case series of pediatric patients treated outpatient for epistaxis by a single otolaryngologist from 2021 to 2022. The primary outcome after treatment with nasal lubricants was defined as (1) refractory epistaxis, (2) improvement, or (3) complete resolution. Cost data for office versus operative nasal cautery were analyzed., Results: In total, 122 patients were included for analysis. Over a follow-up duration of 20.5 months (IQR 8-36), 24.6% of patients experienced refractory epistaxis, 41.8% of patients found improvement, and 33.6% had complete resolution ( n  = 122). Refractory epistaxis was associated with a family history of coagulopathy ( p  = .007), daily epistaxis episodes ( p  = .043), and anemia ( p <.001). Average direct hospital costs associated with nasal cautery were $187 for in-office cauterization and $2179 for intraoperative cauterization. Estimated patient/third party payors savings were $1617 and $15,412 for in-office and intraoperative procedures, respectively, and $541.59 for specialty office visits alone. The average charge for laboratory work-up was $576., Conclusion: Approximately 75% of patients with epistaxis experienced improvement or resolution of symptoms with nasal lubrication alone. Refractory epistaxis was associated with a family history of coagulopathy, daily epistaxis episodes, and anemia. Otolaryngology visits for epistaxis were associated with a direct healthcare expense burden. Adaptation of our clinical model may mitigate these costs while improving patient care. Level of Evidence : 4., Competing Interests: The authors have no conflicts of interest or financial disclosures., (© 2024 The Author(s). Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Conventional therapies for obstructive sleep apnea (OSA), including CPAP and oral appliances, offer the best opportunity for symptomatic improvement and reduction in OSA overall health impact. Integrative medicine brings conventional and complementary approaches together in a coordinated way. With rising obesity rates, weight loss and lifestyle programs seem to be the most favorable integrative methods to combine with conventional OSA therapies. Complementary and integrative approaches to OSA management are varied and, in conjunction with conventional methods, may offer some reduction in the apnea-hypopnea index., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Children with congenital heart defects (CHD) requiring cardiovascular surgery (CVS) rarely require tracheostomy placement; however the mortality rate remains high. The study aimed to analyze the incidence of tracheostomy in children with CHD, and to determine factors contributing to postoperative outcomes, decannulation rates, and mortality., Methods: Retrospective case series of children ≤18 years old with CHD status post-CVS who underwent tracheostomy placement between January 1, 2001 and December 31, 2020. Variables analyzed included demographic information, presence of comorbidities including prematurity, respiratory diseases, presence of genetic syndromes, decannulation status, type of repair (univentricular vs. biventricular), and need for cardiopulmonary bypass. Adverse events analyzed included all-cause mortality, development of mediastinitis, fatal decannulation, and persistence of tracheocutaneous fistula., Results: Fifty-one patients were analyzed. The incidence of tracheostomy was 0.8%. Median age at tracheostomy was 5.3 months. The 5-year survival estimate was 56.3% (95% confidence interval 43.6%, 72.6%). Age ≤6 months at the time of tracheostomy placement ( p  = .03), and the presence of tracheomalacia ( p  = .04) were factors significantly associated with 5-year survival. Two patients (3.9%) experienced fatal decannulation, and one patient (2.0%) developed postoperative mediastinitis. The 10-year decannulation rate estimate was 47.8% (30.5%, 63.2%). Seven patients (13.7%) had a persistent tracheocutaneous fistula., Conclusions: This study corroborates high mortality rates in this population. Factors associated with improved survival were younger age at the time of tracheostomy and presence of tracheomalacia. Decannulation rates were low, but estimates improved over 10 years. Further studies are needed to determine optimal indications and timing for tracheostomy placement in this patient population., Level of Evidence: 4., Competing Interests: The authors have no disclosures or conflicts of interest., (© 2023 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: Solid-organ transplantation (SOT) has become the standard of care for children with terminal organ failure. Long-term immunosuppression has improved survival substantially but is associated with secondary malignancies and impaired wound healing. Our goal was to review the incidence, outcomes, complications, and rate of posttransplant lymphoproliferative disorder on pathologic examination following tonsillectomy/adenotonsillectomy (T/AT) in children after SOT., Study Design: A retrospective cohort study., Setting: Tertiary care children's hospital., Methods: Data were extracted from charts of children with a history of kidney, heart, or liver transplantation, who underwent T/AT between 2006 and 2021., Results: A total of 110 patients met the inclusion criteria, including 46 hearts, 41 kidneys, 19 livers, and 4 liver-and-kidney transplants. The mean age at transplantation was 4.2 years, and the mean transplantation-to-T/AT time interval was 28.8 months. The posttransplant lymphoproliferative disorder was diagnosed in 52 (47.3%) patients, and 25% of these had no tonsillar hypertrophy. There was no difference in age at transplantation, organ received, transplantation-to-T/AT time interval, immunosuppressive medications, tonsil size, or tonsillar asymmetry between patients diagnosed with the posttransplant lymphoproliferative disorder and patients with benign tonsillar/adenotonsillar hypertrophy. Posttonsillectomy complications were similar between the groups., Conclusion: The incidence of posttransplant lymphoproliferative disorder undergoing tonsillectomy for any indication was 47.3%. There was no association between preoperative signs and symptoms and the histopathological diagnosis of posttransplant lymphoproliferative disorder. Stratification by organ received and immunosuppressive medications did not identify differences among the groups relative to the incidence of posttransplant lymphoproliferative disorder and other postoperative complications., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Background: When undergoing tonsillectomy, patients at high risk of thrombosis who require chronic anticoagulation therapy pose a special challenge as bleeding may occur up to 2 weeks after surgery. Because of a lack of evidence-based data, there is no consensus on the best management for such patients. The objective of our study was to review perioperative anticoagulation bridging strategies in children undergoing tonsillectomy., Methods: The study group were a retrospective series of patients on chronic anticoagulation therapy at high risk of a thromboembolic event, who underwent tonsillectomy from 2010 to 2021. Patients whose anticoagulation treatment was discontinued because of a low risk of thromboembolic events were excluded., Results: Four patients met the inclusion criteria (age range, 1.5-16.1 years). All patients were admitted prior to surgery for bridging therapy with intravenous unfractionated heparin (UFH), drip-titrated to a therapeutic dose until 4-6 h prior to surgery. The estimated blood loss during surgery was minimal in all surgeries. Unfractionated heparin was readministered according to the hospital protocol on the night of surgery and titrated to a therapeutic dose. Warfarin was restarted within 2 days postsurgery for all patients. High-risk patients were kept in hospital until postoperative day 6-8 because of concern for delayed bleeding. One patient was noticed to have blood-tinged sputum requiring no intervention; none of the patients developed early or delayed hematemesis., Conclusions: Our data show that bridging therapy with UFH has been successful in chronically anticoagulated patients undergoing tonsillectomy. These patients require multidisciplinary care for the management of their pre- and postoperative course., (© 2022 Japan Pediatric Society.)

Objectives: Neurodevelopmentally impaired (NI) children with chronic sialorrhea are at elevated risk for aspiration and respiratory tract infections. Direct resection or ligation ("DROOL") of the submandibular glands (SMG) with parotid duct ligation are surgical interventions intended to decrease salivary output. The objective of this study is to determine the impact of DROOL surgery on the incidence of nonviral respiratory-related (NVR) post-procedure hospital encounters including emergency department visits and admissions., Methods: Retrospective case series of NVR related outcomes after DROOL surgery in children performed at a single institution, tertiary referral center., Results: A total of 35 gastrostomy tube-dependent patients (60% male, average age 8.2 [SD 6.0] years) with NI underwent DROOL surgery (86% SMG excision). Pre- and post-surgical follow-up time was 3.6 and 3.2 years, respectively. Presurgical and postsurgical NVR hospital encounters occurred in 28 (80%) and 14 (40%) patients, respectively (p < 0.01). Mean (SD) postoperative NVR hospital encounters occurred less frequently when compared to presurgical period (0.4 [0.6] vs. 1.0 [1.2] per year, p < 0.01) with average change of -0.7 encounters per year (SD 1.4, 95% CI -1.0 to -0.2). Patients with encounters within a year preceding DROOL (OR 4.9, p = 0.04, 95% CI 1.1-22.8), or those with at least 3 preoperative encounters (OR 8.0, p = 0.01, 95% CI 1.6-40.3) were significantly associated with a postsurgical NVR event. Fewer patients used anti-sialorrhea medication postoperatively compared to preoperatively (60% vs. 17%, p < 0.01). No patient developed surgical site complications requiring operative interventions., Conclusions: DROOL surgery for chronic sialorrhea in patients with NI was associated with decreased hospitalization and ED visits for NVR respiratory events post-procedurally. Sialorrhea may be an actionable source of recurrent respiratory illnesses requiring hospitalizations., Competing Interests: Declaration of competing interest The authors have no disclosures or conflicts of interest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Conventional therapies for obstructive sleep apnea (OSA), including CPAP and oral appliances, offer the best opportunity for symptomatic improvement and reduction in OSA overall health impact. Integrative medicine brings conventional and complementary approaches together in a coordinated way. With rising obesity rates, weight loss and lifestyle programs seem to be the most favorable integrative methods to combine with conventional OSA therapies. Complementary and integrative approaches to OSA management are varied and, in conjunction with conventional methods, may offer some reduction in the apnea-hypopnea index., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To examine the outcomes of a postoperative day one (POD 1) phone call to families of ambulatory surgical patients, as a means of guiding clinical interventions and quality initiatives, with a focus on children undergoing adenotonsillectomy (T&A)., Methods: Retrospective analysis of outcomes of a POD 1 questionnaire completed in children <18 years of age undergoing T&A at a tertiary care children's hospital over a 3-year period (August 14, 2018-August 31, 2021)., Results: Responses to the questionnaire were obtained for a total of 1428/3464 (41.2%) children undergoing T&A during the study period. There was no difference in gender, age at surgery, race, ethnicity, insurance product, or preoperative diagnosis for those whose caregiver responded to the questionnaire versus those who did not. Parent responses included 84 (5.9%) who reported problems or concerns postdischarge. These included 18 (1.3%) patients unable to take their pain medication, 9 (0.6%) refusing oral intake, 28 (2.0%) with postoperative emesis, 27 (1.9%) with fevers, and 6 (0.4%) with a change in breathing. A total of 75/122 (61.5%) who reported pain were taking their pain medication as directed. Nineteen (1.3%) patients were noted to have bleeding after surgery, including 4 (21.5%) with nosebleeds, and 12 (63.2%) with oral cavity bleeding requiring no interventions., Conclusions: The POD 1 questionnaire identified patients with common concerns and complications after T&A. Although most of these concerns were infrequent, it afforded the clinical team the opportunity to provide additional education and instructions on care and management to caregivers after their child's surgical procedure., Competing Interests: The authors have no disclosures or conflicts of interest., (© 2022 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: To review our experiences with development of a single visit surgery (SVS) program for children with recurrent acute otitis media (AOM) undergoing tympanostomy tube (TT) placement the same day as their otolaryngology surgical consultation., Study Design: Retrospective cohort analysis., Methods: Retrospective series of patients participating in SVS from inception March 1, 2014 to April 30, 2020 were analyzed, with attention to factors associated with increasing interest and participation in SVS and parent experiences/satisfaction., Results: A total of 224 children had TT placed through SVS for AOM management. The average age of patients was 18.1 months (standard deviation 7.8 months), and 130 (58.0%) were male. The median interval between initial contact to schedule SVS, and the SVS date was 15 days (interquartile range 9-23 days). When analyzing year-over-year volumes from inception of SVS, notable increases were seen in 2016 and 2017 after a radio advertisement was played locally. A marked increase in volume was noted after implementation of a Decision Tree Scheduling (DTS) algorithm for children with recurrent AOM. Sixty-six (28.8%) procedures were performed after institution of DTS. A parent survey demonstrated high levels of satisfaction with the SVS experience. Estimations of savings to families in terms of time away from work demonstrated potential for indirect healthcare benefits., Conclusions: SVS for TT placement was a successful, alternative model of care for management of children with AOM. Marketing strategies regarding SVS, and the inclusion of SVS pathway in DTS platforms increased rates of interest and choice of this option. Parents of children undergoing TT through SVS were satisfied with the overall experience., Level of Evidence: 4 Laryngoscope, 131:2823-2829, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To evaluate outcomes of a postoperative telephone questionnaire for children who underwent adenotonsillectomy (T&A). To determine whether episodes of postoperative hemorrhage were not captured until the call, and whether this impacted knowledge of physician rates of hemorrhage., Study Design: Retrospective database analysis., Methods: Retrospective analysis of outcomes of an 11-question data extraction tool utilized at a tertiary care children's hospital for follow-up in T&A patients <18 years of age over a 2-year period. Sub-analysis of positive responses to the question asking about incidence of postoperative hemorrhage., Results: During the study period, 1,068/3,142 (34.0%) parents responded to the phone call. Median age was 6.0 years (interquartile range [IQR] 4.0-8.2), and 566 (53.0%) were male. Ninety (8.4%) noted that the child was still snoring, but only 9 (0.84%) reported signs of obstructed breathing. A total of 402 (37.6%) reported a voice change after surgery. Most children (n = 885, 82.9%) did not receive opioid analgesics, and 252 (23.6%) received acetaminophen/ibuprofen 7 days postoperatively. Return visits to the emergency department were reported in 149 patients; primarily for hemorrhage in 46 (30.8%). In 7 (15.2%) patients, the hemorrhage event was not recorded until the call. The majority-of respondents (n = 1,031, 96.5%) were satisfied with the outcome of the procedure., Conclusions: The postoperative T&A tool provided a means of gathering information on success and satisfaction with surgical outcomes. Children were able to be managed primarily with acetaminophen and ibuprofen. Most complications were captured in the electronic record, although some episodes of hemorrhage were not noted until the call, emphasizing the importance of follow-up., Level of Evidence: 3 Laryngoscope, 131:E2821-E2826, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Does the relationship between the expression of HIV stigma beliefs and the practice of protective sexual behaviors vary by social context? To answer this question, we apply multilevel techniques to Demographic and Health Survey data from seven low HIV prevalence Latin American and Caribbean countries and seven high HIV prevalence Southern African countries to examine contextual variation in this relationship. We examine whether the relationship between stigma beliefs and sexual behaviors differs across these two sets of countries and across regions within each set of countries. We first find that in high prevalence Southern African countries, one unit increases in HIV stigma beliefs are associated with 8% declines in the odds of practicing protective sexual behaviors. Conversely, in low prevalence Latin American and Caribbean countries, unit increases in HIV stigma beliefs are associated with 8% increases in the odds of those same sexual behaviors. Second, the relationship between stigma beliefs and protective sexual behaviors varies across regions within each set of countries, with a wider variance in regional stigma effects located in Southern Africa than in Latin America and the Caribbean. Third, in Southern Africa, the negative effect of stigma beliefs is even more negative in regions where conservative stigma beliefs are pronounced. Overall, our findings demonstrate the importance of taking country and regional context into account when examining the degree to which HIV beliefs affect personal sexual behaviors, which in turn, can contribute to the spread of HIV. Importantly, the implications of our results offer potential guidance to experts who wish to design policies and programs aimed at reducing the expression of negative HIV beliefs towards those infected with HIV., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: To determine demographic and patient variables associated with nothing by mouth (NPO) violations prior to surgery in a tertiary care pediatric hospital., Methods: A retrospective study of patients <18 years of age undergoing elective surgery at a tertiary care children's hospital from 1/1/16 to 4/30/19 who violated their NPO guidelines was performed. Variables associated with a higher rate of NPO violations were analyzed among the different surgical sub-specialties. Additional analyses were performed comparing those with NPO violations to the total group of patients undergoing surgery in the study period., Results: Of the 42 495 children who underwent elective surgical procedures in the study period, 625 (1.5%) committed NPO violations. The median age for those committing a violation was 3 years, and the majority (n = 421, 67.4%) were between 0 and 6 years of age. Otolaryngology patients committing NPO violations had a longer time between scheduling surgery and operative date than other surgical services ( P  < .0001), but a similar time as the urology service. Otolaryngology patients had the highest number of NPO violations (n = 245, 39.2%) compared to the other surgical services, despite doing 32.4% of the total surgical cases ( P  < .001). Children from Spanish-speaking homes accounted for 137 (21.9%) NPO violations, despite accounting for only 11.2% of total surgeries performed. Patients with Medicaid insurance (n = 438, 63.0%) had a higher rate of NPO violations, despite making up 43.6% of total patients., Conclusions: NPO violations occurred in 1.5% of patients during the study period, particularly among the youngest age range of the children analyzed, and they were most prevalent in the otolaryngology patients. Spanish speaking families, and those with Medicaid insurance had higher rates of NPO violations despite making up a smaller percentage of those being operated on overall. This highlighted the need for improvement in communication of fasting guidelines to caregivers., Level of Evidence: 3., Competing Interests: The authors declare no conflicts of interest., (© 2020 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objectives: To determine the polysomnogram (PSG) variables associated with increased incidence of postoperative respiratory complications in children <3 years of age undergoing adenotonsillectomy (T&A) for the management of obstructive sleep apnea (OSA)., Methods: Retrospective case series of children <3 years of age who underwent T&A for the management of OSA at a tertiary care children's hospital from 1/1/08-6/1/2018. Postoperative hospital courses were analyzed to determine if certain clinical or PSG variables might have predicted an increased rate of respiratory complications., Results: A total of 195 children <3 years of age with OSA on preoperative PSGs underwent T&A. The mean age of patients was 25.8 months (range 9-35 months). Seventeen patients (16.2%) had mild OSA, 35 (17.9%) had moderate, and 141 (72.3%) had severe OSA. Most patients (n = 155, 79.5%) required no respiratory intervention postoperatively. Those with severe OSA were more likely to require oxygen support (n = 25, 17.7%) when compared to those with mild-moderate OSA (n = 3, 5.6%). Patients admitted directly to the pediatric intensive care unit (PICU) from the sleep lab (n = 7) had a mean apnea-hypopnea index (AHI) of 63.6 events/hour (range 23-146/hr.), and a mean SpO 2 nadir of 56.3% (range 46-68%). Four of these patients required CPAP after T&A. Of the 7 patients (3.6%) who required intubation after their procedure, only 1 did not have severe OSA, and 2 were intubated to manage post-obstructive pulmonary edema (POPE). Only 4 patients (4.2%) had unplanned PICU admissions. An AHI >12.7 events/hour, >18.5 obstructive apneas, and SpO2 nadir <72.5% were associated with a greater likelihood of requiring postoperative respiratory interventions., Conclusions: Most children <3 years of age, even with severe OSA, had no respiratory issues postoperatively. Those with severe OSA and hypoxemia admitted directly from the sleep lab were more likely to require CPAP postoperatively. All but one patient who developed POPE or who required intubation had severe OSA with associated hypoxemia on their preoperative PSGs., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The rapidly changing health care climate related to coronavirus disease 2019 (COVID-19) has resulted in numerous changes to health care systems and in practices that protect both the public and the workers who serve in hospitals around the country. As a result, these past few months have seen a drastic reduction in outpatient visits. With phased reopening and appropriate guidance, health care systems are attempting to return to normal. The experiences and lessons learned are described, and we provide guiding principles to allow for a safe and effective return to outpatient care.

The COVID-19 pandemic has created a situation unparalleled in our lifetime. As the medical community has attempted to navigate a sea of ever-changing information and policies, this uncertainty has instead bred creativity, community, and evolution. Necessity is the mother of invention, and one of the by-products of our rapidly changing environment is the increased reliance on telemedicine. Here, we discuss our experience with incorporating telemedicine into an urban academic pediatric otolaryngology practice, the challenges that we have encountered, and the principles unique to this population.

Objective: To provide evolving information on active protocols regarding inpatient, outpatient, procedural, and surgical case management taking place in otolaryngology practices in response to COVID-19., Study Type: Cross-sectional multi-institutional survey., Methods: An online survey of 55 otolaryngology departments across North America., Results: As of March 25, 2020, almost all (n = 53 of 55, 96.3%) otolaryngology departments had canceled elective cases and were performing only urgent consults. Most residents continued to participate in operative cases (n = 45 of 49, 91.8%) and take call (n = 48 of 50, 96.0%). Of the respondents, 27 of 29 (93.1%) stated that they were deferring nonemergent tracheostomy procedures for the time being. The use of personal protective equipment followed a general trend of an increasing level of protection with an increased risk of the procedure; most (n = 49 of 54, 90.7%) incorporated N95 mask usage for bedside/clinic examinations with flexible laryngoscopy. Powered air-purifying respirators and N95 masks were used mainly for procedures involving the mucosal surfaces., Discussion: Due to the high viral density in the nasal cavity and nasopharynx of patients with COVID-19, basic examinations and common otolaryngology procedures place practitioners at high risk of exposure. Although there is variability in practice among otolaryngologists across North America in managing the COVID-19 outbreak, most are primarily seeing urgent ambulatory and inpatient consultations. Most are also incorporating personal protective equipment appropriate to the level of transmission across mucous membranes., Implications for Practice: In these rapidly evolving times, it is helpful to find solidarity and assurance among health care providers. Current data aimed to provide (1) perceived methods regarding the safe care of otolaryngology patients and (2) updated practice patterns at a national level.

The rapidly changing health care climate related to coronavirus disease 2019 (COVID-19) has resulted in numerous changes to health care systems and in practices that protect both the public and the workers who serve in hospitals around the country. As a result, these past few months have seen a drastic reduction in outpatient visits and surgical volumes. With phased reopening and appropriate guidance, health care systems are attempting to return to normal. Our institution has had the unique opportunity to already return operations back to full capacity. The experiences and lessons learned are described, and we provide guiding principles to allow for a safe and effective return to patient care., (© The Authors 2020.)

Objective: Laryngomalacia has been reported to contribute to the severity of obstructive sleep apnea (OSA) in children. It is unclear if surgical treatment of laryngomalacia improves polysomnography (PSG) outcomes in these patients. The objective of this study is to report the impact of supraglottoplasty on PSG parameters in children with laryngomalacia-related OSA., Study Design: Retrospective case series., Setting: Tertiary care medical center., Subjects and Methods: Historical cohort study of consecutive children with laryngomalacia who underwent supraglottoplasty and who had undergone overnight PSG before and after surgery., Results: Forty-one patients were included in the final analysis: 22 (53.6%) were male, and 19 (46.3%) were female. The mean ± SEM age of patients at preoperative PSG was 1.3 ± 0.89 years (range, 0.003-2.9). In entire cohort, the mean obstructive apnea-hypopnea index score was reduced from 26.6 events/h before supraglottoplasty to 7.3 events/h after surgery ( P = .003). Respiratory disturbance index was reduced from 27.3 events/h before supraglottoplasty to 7.8 events/h after surgery ( P = .003). The percentage of REM sleep decreased from 30.1% ± 2.4 to 24.8% ± 1.3 ( P = .04). Sleep efficiency was improved ( P = .05)., Conclusion: Overall, supraglottoplasty significantly improved several PSG outcomes in children with laryngomalacia. However, mild to moderate OSA was still present postoperatively in most children. This suggested a multifactorial cause for OSA in this population.

Objective: Returns to the emergency department (ED) for pain or dehydration after adenotonsillectomy (T&A) are frequent. Attempts to associate the specific pain regimens with these visits have been unrevealing, suggesting a need to assess for other potential factors associated with readmission., Methods: A review of a 2:1 cohort matched by age, gender and payer status compared post-T&A patients who did not return ED for pain or dehydration within 21 days to those who returned. Factors investigated included patient demographics, comorbidities, medication regimen and the presence of postoperative telephone encounters. Patients returning to the ED were further assessed for rates of medication adherence., Results: 7493 patients underwent T&A during the period. Of these, 144 (1.9%) returned for pain/dehydration. Comparison to 285 matched patients revealed an association between ED returns and Hispanic ethnicity (p < 0.001), Spanish language (p = 0.0002), and comorbid Down syndrome and ADHD (p = 0.011 in both). The incidence of parent telephone calls to the office was associated with ED returns (58.7 in the ED cohort, 28.4% in non-ED cohort, p < 0.0001). On multivariable analysis, Hispanic ethnicity and phone calls were associated with ED returns (p < 0.0001 and p < 0.0001, respectively). Only 64.0% of patients returning to the ED were adherent with postoperative pain regimens., Conclusions: While demographic factors may be associated with rate of ED returns for pain and dehydration, post-operative phone calls were most highly associated with returns. The majority of patients returning to the ED were non-adherent with recommended pain regimens, suggesting an opportunity to investigate medication adherence in all post-tonsillectomy patients., (Copyright © 2019. Published by Elsevier B.V.)

Objective: Identify demographic variables related to emergency department (ED) returns, and analgesic administration in the ED for postoperative pain after adenotonsillectomy (T&A)., Study Design: Pediatric Health Information System (PHIS) database analysis., Methods: Forty-seven children's hospitals included in the PHIS database were queried for all ED visits within 30 days of surgery with a diagnosis of acute postoperative pain (n = 2459) from 2014 to 2015. The subset of postoperative T&A patients (n = 861) was further analyzed for variables associated with return, and for pain management strategies, specifically opioids, employed by the ED., Results: Of the 2459 pediatric patients returning to the ED for acute postoperative pain, the largest subset included T&A patients (n = 861, 35%). Patients were seen an average of 4 days (SD 2.4) after their surgery. ED administration of opioids was not associated with gender, race, surgical diagnosis, or ethnicity. The rate of opioid administration by the ED increased with advancing age of the children analyzed ( P = .01). The incidence was also higher for those with commercial versus Medicaid insurance carriers. A total of 204 (23.7%) patients received opioids while in the ED, 439 (51%) received both opioids and non-opioids, and only 51 (5.9%) received no pain medication., Conclusion: T&A patients make up the largest subset of patients returning to the ED for postoperative pain. A total of 74.7% of patients receive opioids, either alone or in combination with non-opioids, on return to the ED. ED opioid administration was associated with older age of the child and payer, but not with gender, race, surgical diagnosis, or ethnicity., Level of Evidence: 4.

Purpose: Airway management in neonates with Pierre Robin sequence (PRS) can be challenging. The goal was to describe the algorithm developed by the authors over the past 8 years., Methods: A retrospective case series analyzing airway management in neonates with PRS admitted to the neonatal intensive care unit at a tertiary care pediatric hospital was performed. The utility of the proposed algorithm for airway management incorporating more consistent use of polysomnography (PSG), and airway assessment was assessed., Results: A total of 31 neonates with PRS (12 men, 19 women) with a mean gestational age of 38.2 weeks were analyzed. Thirteen (41.9%) patients had a named syndrome, chromosomal abnormality, or global delay. Twenty (64.5%) patients had pre-intervention PSG, and severe obstructive sleep apnea with an apnea-hypopnea index (AHI) ≥ 10 events/hour was identified in 19 (95.0%). Mandibular distraction osteogenesis was performed in 18 (58.1%) patients, and improved the AHI on post-operative PSGs. Direct assessment of the upper and lower airways was performed in 19 patients, and 13 (68.4%) were found to have secondary airway pathology. Presence of a concomitant syndrome was significantly associated with need for tracheostomy., Conclusion: The algorithm differs from previous ones in that it relies on rigorous pre- and post-intervention PSG (including with a nasopharyngeal airway), as well as that it allows flexibility between treatment options given the whole-patient clinical scenario and endoscopic findings. Results from these studies may be integrated to stratify patients into those who are most likely to benefit from conservative interventions or surgical procedures.

Introduction: Residual obstructive sleep apnea (OSA) after adenotonsillectomy (T&A) is a common problem in children with Down Syndrome (DS). Our objective was to describe trends in surgical and medical management of OSA in pediatric patients with DS, and to present an algorithmic approach to managing these children., Methods: Retrospective case series of children with DS seen at a tertiary care medical center between 1/2008-6/2016 who underwent polysomnography (PSG) after having a T&A performed for sleep disordered breathing (SDB)., Results: Sixty-five patients met inclusion criteria. The mean age at T&A was 4.8 years and 52.0% were male. The mean apnea-hypopnea index (AHI) was 23.2 events/hour for patients who had pre-T&A PSGs. The mean AHI was 10.7 events/hour after T&A. Twenty-three patients (35.4%) underwent at least one additional surgical procedure after T&A; 5 (7.7%) patients had ≥ two additional procedures. The most common additional surgical procedures were revision adenoidectomies (n = 8) and lingual tonsillectomies (n = 13). Fifteen (23.1%) patients underwent at least one drug-induced sleep endoscopy (DISE) to help direct selection of surgical site/s., Conclusions: Residual OSA is common after T&A in children with Down syndrome and can be managed by additional surgical interventions in many instances with successful reduction of the AHI. DISE has become part of a standard algorithm for managing persistent OSA in children with Down syndrome after T&A., (Copyright © 2018. Published by Elsevier B.V.)

Introduction: The high incidence of chronic otitis media with effusion and Eustachian tube dysfunction in children with Down syndrome (DS) may predispose them to cholesteatoma formation. Establishing the diagnosis, choosing the appropriate operative intervention, and post-operative care can be challenging., Objective: To describe management strategies for cholesteatoma diagnosis, surgical treatment, and post-operative management in children with Down syndrome., Methods: Retrospective case series of 14 patients (17 total ears) with Down syndrome diagnosed with cholesteatoma over a 9-year period., Results: A total of 14 patients with cholesteatoma (3 with bilateral disease) were analyzed. Thirteen ears (76.5%) had ≥2 tympanostomy tubes insertions prior to cholesteatoma diagnosis, and otorrhea and hearing loss were the most common presenting symptoms. Common pre-operative CT scan findings included mastoid sclerosis and ossicular erosion. The average age at first surgery was 9.8 years, and the average follow-up was 4.3 years. For acquired cholesteatoma, most ears were managed with canal wall up (CWU) approaches, but ultimately 6/15 (40.0%) required canal wall down (CWD) approaches. Postoperatively, 3 (20.0%) ears developed new tympanic membrane retraction pockets, but no recurrent cholesteatoma. Four (26.7%) ears developed recurrent disease, and 3 (20.0%) had residual disease at secondary procedures. Ossiculoplasty was performed in 4 ears. Twelve (70.6%) ears were rehabilitated with hearing aids or FM systems., Conclusions: The diagnosis of cholesteatoma in Down syndrome was associated with otorrhea, hearing loss, and CT scan findings of ossicular erosion and mastoid sclerosis. Most cases were managed with CWU surgical approaches. Hearing aid use was common post-operatively., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: The prevalence of chronic otitis media with effusion (COME), and Eustachian tube dysfunction (ETD) is high in Down syndrome (DS) patients. This often necessitates multiple tympanostomy tube (TT) placements resulting in a higher rate of persistent tympanic membrane (TM) perforation requiring tympanoplasty for repair., Objectives: To assess risk factors for persistent perforation and outcomes of tympanoplasty in DS patients., Methods: Retrospective case series of 91 ears in 69 DS patients with TM perforations, who were either observed or underwent tympanoplasty. Clinical features, surgical outcomes, and hearing outcomes were assessed., Results: 91 ears were evaluated. Sixty perforations were observed, and 31 perforations were repaired. The closure rate was 54.8% for primary surgery, and 70.9% after secondary surgical interventions in the Tympanoplasty Group, compared to 33.0% spontaneous closure rate in the Observation Group (p < 0.001). The only risk factor for failed tympanoplasty repair was persistent COME/ETD (OR 27.2, p = 0.001). In the Observation Group perforations diagnosed at an older age, with >3 TT insertions, and with persistent COME/ETD were less likely to close spontaneously. Patients undergoing tympanoplasty had worse preoperative pure tone averages than those being observed, but significant improvement in air-bone gaps were noted in the Tympanoplasty Group (p = 0.02) post-operatively. Patients were often rehabilitated with hearing aids regardless of intervention (53.3% Observation Group, 48.4% Tympanoplasty Group)., Conclusions: Persistent TM perforation in children with Down syndrome was associated with a history of COME/ETD, and multiple prior TT insertions. Tympanoplasty was successful for repair in most patients who underwent surgical intervention, but residual hearing loss was common., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives/hypothesis: To describe the presentation and management of acute complicated mastoiditis in children., Study Design: Retrospective case series., Methods: An analysis of pediatric patients with acute complicated mastoiditis treated at an urban, tertiary care children's hospital from 2007 to 2014 was performed., Results: Forty-eight patients presented with a total of 67 complications of acute mastoiditis. Mean age at presentation was 4.8 years (range = 0.1-15.3 years). The most common complications were subperiosteal abscess (n = 22, 45.8%), epidural abscess (n = 16, 33.3%), and sigmoid sinus thrombosis (n = 14, 29.2%). The most common pathogens isolated included Streptococcus pneumoniae (n = 14, 29.2%) and group A streptococcus (n = 10, 20.8%). Multidrug resistance was not associated with complication type. Surgical management included myringotomy ± tympanostomy tube placement in 46 (95.8%) patients (the only surgery in 10), drainage of subperiosteal abscess without mastoidectomy in 18 (37.5%) patients, and mastoidectomy in 21 (43.8%) total patients. Patients presenting with intracranial complications were the most likely to undergo a mastoidectomy. Anticoagulation was used in the management of nine of 14 (64.3%) patients presenting with sigmoid sinus thrombosis. Neurosurgical interventions (n = 7, 14.6% patients) were primarily performed to manage increased intracranial pressure., Conclusions: Subperiosteal abscess was the most common complication of acute mastoiditis, and when occurring as the sole complication was successfully managed with antibiotics and surgical intervention that did not include mastoidectomy. Epidural abscess and sigmoid sinus thrombosis were more prevalent than reported in prior series and were managed more aggressively. These patients were more likely to need neurosurgical interventions., Level of Evidence: 4. Laryngoscope, 127:2321-2327, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To analyze the association between sleep duration, metabolic variables, and insulin resistance in obese children with and without obstructive sleep apnea. The decline in sleep duration has paralleled a dramatic increase in the prevalence of obesity and diabetes, suggesting a mechanistic relationship., Study Design: Retrospective, case series., Methods: Consecutive obese patients 3 to 12 years of age who underwent polysomnography (PSG) and a metabolic panel and who completed a 14-item sleep questionnaire were analyzed. All laboratory testing was conducted within 3 months of PSG. Total sleep times were obtained from the PSG and confirmed by the questionnaire., Results: A total of 171 patients (55.0% male) were studied. All patients were obese (body mass index [BMI] z score > 95th percentile). Patients were categorized into three groups: short sleepers, borderline sleepers, and optimal sleepers. Eighty-six (50.3%) patients were short sleepers, 71 (41.5%) were borderline sleepers, and 14 (8.2%) were optimal sleepers. The mean BMI z score was 3.13 ± 1.3 in short sleepers, 3.3 ± 1.1 in borderline sleepers, and 3.5 ± 1.5 in optimal sleepers (P = .39). There was no statistical difference in high- and low-density lipoprotein levels (P = .21 and P = .76, respectively) and total cholesterol (P = .43) among subgroups. Triglycerides, blood glucose, insulin, and homeostasis model assessment-insulin resistance were significantly higher in short sleepers when compared to borderline or normal sleepers (P = .008, P < .001, P < .001, and P < .001, respectively)., Conclusions: Short sleep duration was correlated with alterations in metabolic variables and insulin resistance in obese patients. This raises concern for development of comorbid conditions that can persist into adulthood., Level of Evidence: 4 Laryngoscope, 127:2176-2181, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine the feasibility of providing streamlined same-day evaluation and surgical management of children with recurrent otitis media or chronic serous otitis media who meet criteria for tympanostomy tube (TT) placement., Study Design: Retrospective matched case series., Setting: Tertiary care children's hospital., Methods: A comparison group (age, sex, insurance product) was utilized to determine if the same-day process decreased facility time and surgical time for the care episode. A parent satisfaction survey was administered., Results: Thirty children, with a median age of 16 months (range, 12-22 months), participated in the same-day surgery process for TT. Twenty-one patients (70.0%) were male, and these patients were matched to a comparison group (similar age, sex, and insurance product) having non-same-day (routine) TT placement. The same-day patients spent significantly less time in clinic for the preoperative physician visit (average, 15 minutes) when compared with the non-same-day patients (average, 51.5 minutes; P < .001). The operative experience for the same-day patients was similar to the non-same-day patients (average, 145 vs 137 minutes, respectively; P = .35), but the overall experience was significantly shorter for the same-day patients (average, 151 vs 196 minutes for comparisons; P < .001). All parents surveyed in the same-day group were satisfied with the efficiency of the experience., Conclusion: The same-day surgery process for management of children who meet the criteria for TT placement is a model of improved efficiency of care for children who suffer from otitis media., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objectives/hypothesis: To identify the rate of hearing loss related to middle ear disease and the frequency of tympanostomy tube (TT) insertion in the contralateral ear of patients with unilateral microtia/aural atresia., Study Design: Retrospective case series of patients less than 3 years of age with unilateral microtia/aural atresia treated at an urban, tertiary care children's hospital from 2008 to 2013., Methods: Clinical and audiologic data were reviewed. Statistical analysis was performed to determine the relative risk of TT insertion in the normal ear., Results: A total of 72 patients were included for analysis. The average age of patients at their initial otolaryngology visit was 3.3 months (range 0.08-1.67 years); 38 (52.8%) patients were males. Aural atresia involved the right ear in 43 (59.7%) cases. Five (6.9%) patients were syndromic. Abnormal audiometric testing of the normal ear was noted in 12 (16.7%), and 14 (19.4%) underwent TT during the first 3 years of life. Twelve children (85.7%) who had a TT placed were nonsyndromic. When compared to published norms for TT placement in the general population (6.8% of children < 3 year of age), a greater proportion of children with unilateral microtia/aural atresia had TT placement in the normal ear (z = 4.26, P < 0.0001)., Conclusion: Patients with unilateral microtia/aural atresia have increased rates of hearing loss and middle ear effusion leading to TT in their normal ear at a higher rate versus the general population. This information can help guide more vigilant care and audiologic follow-up in affected children., Level of Evidence: 4. Laryngoscope, 126:1470-1474, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Obesity is one of the leading health concerns in developed and in developing countries. The risk of obstructive sleep apnea (OSA) is greatly increased by obesity. Obesity is known to be associated with the Metabolic Syndrome and cardiovascular disease in adults. This same association in children is not well defined. Understanding the relationship of obesity, OSA, and metabolic alterations in children would improve understanding of the risks of cardiovascular disease into adulthood., Objective: To evaluate the association of OSA and metabolic outcomes, including lipid variables and insulin resistance, in obese adolescents., Methods: Retrospective, case-control series at a tertiary care children's hospital. Obese adolescents aged 12-18 years who underwent overnight polysomnography (PSG) and routine laboratory testing for lipid levels, fasting glucose, and insulin from January 1, 2006 to December 31, 2012., Results: A total of 42 patients with a mean age of 14.1±1.9 years were analyzed. Nineteen (45.2%) were male. The mean body mass index (BMI) z score was 2.23±0.86, and all patients were obese (BMI z score >95th percentile). Triglyceride, fasting blood glucose, insulin, and homeostasis model assessment-insulin resistance (HOMA-IR) levels were significantly higher in patients with OSA when compared to those with No-OSA (p<0.01). There was incremental worsening of insulin and HOMA-IR with greater severity of OSA. The apnea-hypopnea index (AHI) was positively and significantly correlated with blood glucose and HOMA-IR (p=0.01and p<0.001, respectively). Multiple linear regression analysis showed that the AHI was a predictor of blood glucose (p=0.04) and HOMA-IR (p=0.01) independent of age, gender, total sleep time and BMI z score. Logistic regression analysis showed that elevated levels of blood glucose predicted severe OSA (p=0.02) independent of gender and BMI z score. Elevation in HOMA-IR predicted severe OSA (p=0.004)., Conclusion: OSA severity is associated with increased fasting insulin, blood glucose and HOMA-IR even after controlling for the age, and BMI z score in adolescents., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Tonsillectomy is a frequently performed surgical procedure in children; however, few multimodal analgesic strategies have been shown to improve postsurgical pain in this patient population. Systemic magnesium infusions have been shown to reliably improve postoperative pain in adults, but their effects in pediatric surgical patients remain to be determined. In the current investigation, our main objective was to evaluate the use of systemic magnesium to improve postoperative pain in pediatric patients undergoing tonsillectomy. We hypothesized that children who received systemic magnesium infusions would have less post-tonsillectomy pain than the children who received saline infusions., Methods: The study was a prospective, randomized, double-blinded, clinical trial. Subjects were randomly assigned using a computer-generated table of random numbers to 1 of the 2 intervention groups: systemic magnesium infusion (initial loading dose 30 mg/kg given over 15 minutes followed by a continuous magnesium infusion 10 mg/kg/h) and the same volume of saline. The primary outcome was pain scores in the postanesthesia care unit (PACU) measured by FLACC (Face, Legs, Activity, Cry, Consolability) pain scores. Pain reduction was measured by the decrement in the area under the pain scale versus 90-minute postoperative time curve using the trapezoidal method. Secondary outcomes included opioid consumption in the PACU, emergence delirium scores (measured by the pediatric anesthesia emergence delirium scale), and parent satisfaction., Results: Sixty subjects were randomly assigned and 60 completed the study. The area under pain scores (up to 90 minutes) was not different between the study groups, median (interquartile range [IQR]) of 30 (0-120) score × min and 45 (0-135) score × min for the magnesium and control groups, respectively (P = 0.74). Similarly, there was no clinically significant difference in the morphine consumption in the PACU between the magnesium group, median (IQR) of 2.0 (0-4.44) mg IV morphine, compared with the control, median (IQR) of 2.5 (0-4.99) mg IV morphine (P = 0.25). The serum level of magnesium was significantly lower in the control group than in the treatment group at the end of the surgery (P < 0.001)., Conclusions: Despite a large number of studies demonstrating the efficacy of systemic magnesium for preventing postsurgical pain in adults, we could not find evidence for a significant clinical benefit of systemic magnesium infusion in children undergoing tonsillectomies. Our findings reiterate the importance of validating multimodal analgesic strategies in children that have been demonstrated to be effective in the adult population.

Objective: To identify the relationship of pediatric temporal fractures to the incidence and type of hearing loss present. To analyze the timing and utility of audiometric testing in children with temporal bone fractures., Methods: Retrospective case series of 50 pediatric patients with temporal bone fractures who were treated at an urban, tertiary care children's hospital from 2008 to 2014. A statistical analysis of predictors of hearing loss after temporal bone fracture was performed., Results: Fifty-three fractures (69.7%) in 50 patients involved the petrous portion of the temporal bone. The mean age of patients was 7.13 years, and 39 (73.6%) were male. A fall was the most common mechanism of injury in 28 (52.8%) patients, followed by crush injury (n=14, 26.2%), and vehicular trauma (n=10, 18.9%). All otic capsule violating fractures were associated with a sensorineural hearing loss (n=4, 7.5%, p=0.002). Three of four otic capsule sparing fractures were associated with ossicular dislocation, with a corresponding mixed or conductive hearing loss on follow up audiometric testing. The majority of otic capsule sparing fracture patients (n=19/43, 44.2%) who had follow up audiograms had normal hearing, and those with otic capsule violating fractures were statistically more likely to have persistent hearing loss than those with otic capsule sparing fractures (p=0.01)., Conclusions: Patients with otic capsule violating fractures or those with ossicular disruption are at higher risk for persistent hearing loss. Cost-saving may be accrued by selecting only those patients at high risk for persistent hearing loss for audiometric testing after temporal bone fractures., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Importance: There is a perceived increase in the number of microdirect laryngoscopies and bronchoscopies (MLBs) required on premature infants, infants with syndromic conditions, and those with complex congenital heart defects. Determining which neonates with certain underlying conditions require more aggressive interventions like tracheostomy, intubation, or supraglottoplasty might be useful for future preoperative planning and counseling of the families of newborns with complex medical conditions involving the airway., Objectives: To evaluate features and findings in neonates undergoing MLB in the first 28 days of life over a 10-year period and compare these findings with past publications., Design, Setting, and Participants: Retrospective case series of 162 consecutive patients 28 days or younger undergoing MLB between January 1, 2002, and December 31, 2012, at a tertiary care children's hospital., Intervention: Microdirect laryngoscopy and bronchoscopy., Main Outcomes and Measures: Frequencies of common indications and findings in neonates undergoing MLB. To determine if findings on MLB had significant associations with gestational age, neonates with cardiac defects or syndromic conditions, and neonates who had at least 1 other comorbid condition, χ2 and Fisher exact tests were performed. Similar associations were analyzed between neonates with other comorbid conditions and need for interventions such as supraglottoplasty, tracheostomy, and intubation., Results: Of the 162 patients, 101 were male (55.5%). The mean age at their procedure was 14.1 days. The mean weight of patients at MLB was 3.31 kg, and 32 (17.6%) were premature. Congenital conditions were noted in 114 patients (62.6%), and of these, 55 (30.2%) had congenital cardiac disease and 30 (16.4%) had syndromic conditions. Common indications for surgery were respiratory distress (n = 145 [79.7%]), stridor (n = 102 [56.0%]), and cyanosis or an acute life-threatening event (n = 67 [36.8%]). The most common findings at the time of surgery were laryngomalacia (n = 71 [39.0%]), subglottic stenosis (n = 58 [31.9%]), and tracheomalacia (n = 47 [25.8%]). Seventeen neonates (9.3%) required a tracheostomy, and 11 (6.0%) required a supraglottoplasty. Neonates with congenital heart defects were statistically significantly more likely to require long-term intubation (n = 9 [16.4%]; P = .03). Those with syndromic conditions were more likely to require long-term intubation and tracheostomy (n = 7 [23.3%] [P = .004] and n = 7 [23.3%] [P = .01], respectively). Premature infants who required MLB had a decreased incidence of laryngomalacia (n = 7 [21.9%]; P = .03), and those with comorbid conditions, an increased incidence (n = 43 [33.3%]; P = .01). There was minimal morbidity directly associated with the procedure., Conclusions and Relevance: Neonates undergoing MLB most commonly presented with respiratory distress and stridor and were most commonly found to have laryngomalacia and subglottic stenosis. More than half of the patients studied had other comorbid conditions. Those with cardiac defects and syndromic conditions were more likely to require intubation, and those with syndromic conditions were more likely to eventually undergo tracheostomy.

Objective: To evaluate the work-up and treatment of pediatric epistaxis in an outpatient clinical setting, with a focus on the diagnostic utility and associated costs of nasal endoscopy and adjunctive laboratory data., Study Design: Retrospective, case series., Methods: Children under 18 years of age seen in an outpatient clinical setting at a tertiary care hospital between 2004 and 2012 for the primary diagnosis of epistaxis were identified. Patient characteristics were analyzed from a statistical and cost perspective., Results: A total of 175 patients with epistaxis were included. One hundred twenty-two (69.7%) were male, with a mean overall age of 9.1 years (range 5 months to 17.9 years). The duration of bleeding ranged from 0.25 to 84 months (mean 11.5 months). Nasal endoscopy was performed in 123 (70.2%) patients. Three (2.4%) had nasal polyps, and 1 (0.8%) a juvenile nasopharyngeal angiofibroma. The average age of patients with nasal masses was significantly older (16.2 years versus 10.4 years, p=0.008). Of 131 patients with available blood work, laboratory values demonstrated anemia in 27 (20.6%) patients, elevated partial thromboplastin time in 5 (3.8%), and an abnormal platelet function analysis in 1 (0.8%) patient. Those with anemia were statistically younger (p=0.001), than those with either normal labs or abnormal coagulation studies. Epistaxis resolved in 88/135 (65.2%) who had follow-up visits., Conclusion: The majority of pediatric epistaxis cases resolved with nasal mucosa hydration. Nasal endoscopy can be reserved for teenaged patients with epistaxis, and routine laboratory screening may be useful in select cases based on the clinical judgment., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Importance: The incidence of obesity is rising in the United States and has been linked to Obstructive Sleep Apnea (OSA) even in young children. Understanding the role that obesity and OSA play in alterations in metabolic variables that can lead to serious health issues is essential to the care and counseling of affected children., Objectives: To evaluate the association of alterations in metabolic variables, including insulin resistance, to OSA in young, obese children., Design: Retrospective, case-control series., Setting: Tertiary care children's hospital., Participants: Obese children aged 2-12 years who had undergone overnight polysomography and routine laboratory testing for lipid levels, fasting glucose, and insulin from January 1, 2006 to December 31, 2012 were identified from a TransMed Bio-Integration Suite and Epic's clarity database search., Results: A total of 76 patients were included for analysis. Forty-three (56.6%) were male, and the mean age was 8.3±2.5 years (range, 2.4-11.9 years). The mean body mass index (BMI) z score was 2.8±0.75 (range, 1.7-6.3), and all patients were obese (BMI z score>95th percentile). Twenty two patients (28.9%) had an apnea-hypopnea index (AHI) <1/h (no OSA), 27 (35.5%) an AHI≥1<5/h, 12 (15.8%) had an AHI ≥5<9.99/h, and 15 (19.7%) had an AHI≥10/h. There was no significant difference in total cholesterol, triglycerides, high and low density lipoprotein levels, systolic and diastolic blood pressure in those patients with or without OSA. Fasting insulin, blood glucose, and homeostasis model assessment (HOMA) were significantly higher in patients with OSA compared to those with no OSA (p<0.01). AHI correlated to alterations in insulin as well as glucose homeostasis on multivariate analysis. Results from logistic regression analysis showed that fasting insulin (p<0.01), and HOMA (p<0.01) predicted severe OSA independent of age, gender, and BMI z score in these patients., Conclusion: Metabolic alterations in glucose and insulin levels, known to be associated with obesity and increased risk for cardiovascular disease, appear to relate to the severity of OSA in young children., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

The purpose of this article is to familiarize the otolaryngologist with complementary and integrative treatment options for the management of sore throat and tonsillitis. A review of the available literature will provide insight into available treatment options with these therapies. Current medical and surgical approaches to therapy for adenotonsillar disease will be reviewed., (Copyright © 2013 Elsevier Inc. All rights reserved.)

This article familiarizes the otolaryngologist with potential integrative and complementary treatment options for obstructive sleep apnea syndrome. The authors discuss current medical and surgical regimens, and then provide a review of the current literature on integrative and complementary approaches for treatment of this disorder., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: No studies are available specifically comparing revision rates between suction coagulator and microdebrider-performed adenoidectomies. Our objective was to compare revision adenoidectomy rates between these instrument groups., Study Design: Historical cohort study., Setting: Patients included in this study had surgery at the Ann and Robert H. Lurie Children's Hospital in Chicago, Illinois, from June 2007 through December 2011., Subjects and Methods: The patients were divided into 2 groups based on technique of adenoidectomy used at the time of initial surgery and the regrowth rate analyzed., Results: During the 4.5-year study period, the microdebrider was used in 4071 adenoidectomies, and 3328 cases were performed with suction coagulation. There was a revision rate of 0.84% (34 patients) for the microdebrider group. The rate was 1.50% (50 patients) for suction coagulation. This difference was found to be statistically significant on univariate analysis. The suction coagulator group had a younger mean age at initial surgery and a higher incidence of gastroesophageal reflux disease. No difference in revision rates between the 2 groups was noted on multivariate analysis., Conclusion: Symptomatic regrowth of adenoid tissue occurs infrequently. Both suction coagulation and microdebrider methods are commonly used when performing adenoidectomies due to more consistent ease of use in removal of tissue. The incidence of regrowth likely relates to variables other than the technique used, as there was no difference in the regrowth rate between the 2 groups.

Objective: To review our experience with suppurative complications of acute otitis media (AOM) in the era of antibiotic resistance, given a perceived increase in the number of such cases in recent years requiring surgical intervention., Design: Retrospective review of pediatric patients presenting with suppurative complications of AOM from January 1993 to June 2000., Setting: Academic tertiary care children's medical center., Patients: A total of 90 pediatric patients, ranging in age from 3 months to 16 years (mean age, 45 months)., Results: A total of 104 suppurative complications of AOM occurred in 90 patients over the 7.5-year study period. The incidence of noncoalescent, coalescent, and total cases of mastoiditis and total number of suppurative complications all increased over the study period, with coalescent outpacing noncoalescent disease during the last 3 years of the study. A trend toward an increasing number of cases requiring surgical intervention was noted during the study period, corresponding to an increasing number of resistant Streptococcus pneumoniae isolates. Ten of 16 S pneumoniae isolates were resistant, primarily collected from younger children ranging in age from 4 to 24 months (mean age, 11.9 months)., Conclusion: The rising incidence of resistant S pneumoniae corresponded to the increasing number of suppurative complications of AOM during the study period and seemed to contribute to more aggressive infectious processes requiring surgical intervention.

Purpose: To report a series of patients with hemangiopericytoma (HP) of the head and neck, to review pathological features of these tumors, and to discuss management options., Materials and Methods: A retrospective review of the medical records at the University of California, Los Angeles (UCLA) Medical Center in Los Angeles, CA, was done in order to identify those patients with primary HP of the head and neck, including soft tissue and mucosal sites., Results: Ten patients with HP of the head and neck were identified. There was an equal sex distribution and an average age of 36 (range 10-65). Seven of the tumors arose from soft tissue sites in the head and neck, and the remaining 3 arose from the mucosa. All patients underwent wide excision of the primary lesion with a local recurrence rate of 40%. Thirty percent of patients developed metastatic lung disease 0 to 8 years after initial diagnosis. Each patient who developed metastatic disease had abundant mitoses on pathological review compared with rare or absent mitoses in the lesions that took a more benign course., Conclusions: Pathological appearance of resected HP is predictive of later metastatic potential. Long-term follow-up is necessary in patients even after radical resection because recurrence or metastasis may be delayed by many years.

Objective: To determine how sinus disease noted on pre-bone marrow transplant (BMT) screening sinus computed tomography (CT) scans relates to subsequent development of clinical and/or radiographic sinusitis and correlates with overall prognosis., Methods: A retrospective review of medical records, CT scans, and BMT database statistics was performed on all pediatric BMT recipients from January 1992 through December 1997. Fifty-four pre-BMT CT scans were performed on 51 children, aged from 2 months to 17 years. Sinus disease was staged according to criteria established by Lund and Kennedy [V.J. Lund, D.W. Kennedy, Ann. Otol. Rhinol. Laryngol. S167 (1995) 17-21.]., Results: The average age of BMT recipients was 6.8 years. Most common oncologic diagnoses included acute myelogenous leukemia (37%), acute lymphoblastic leukemia (17%), and stage IV neuroblastoma (13%). Screening sinus CT scans were routinely performed 1-3 months prior to BMT. On pre-BMT CT scans 48% of the patients had no evidence of sinus disease, 25.9% mild disease, 9.3% moderate disease, and 16.7% severe disease. Two-thirds (66.7%) of patients with severe sinus disease on pre-BMT CT scans experienced clinical sinusitis post-BMT. In contrast, sinus symptoms were much less common (21.4%) in those with mild disease on CT scan. Overall, 39.3% of patients with sinus abnormalities on pre-BMT CT scans had clinical sinusitis during their post-BMT course, compared to 23.1% of those with normal CT scans pre-BMT. In addition, those patients demonstrating sinus disease on their pre-BMT CT scan were more likely to have radiographic sinusitis post-BMT (25.0%) than those with no disease (7.7%). Seventy-eight percent of those with severe sinusitis had died by 2-year follow up, compared to 69.2% of patients with normal CT scans pre-BMT., Conclusions: Severity of radiographic sinus disease on pre-BMT CT scans was noted to correlate with clinical and radiographic sinusitis later in the post-BMT course, and was associated with a trend toward decreased survival. Pre-BMT CT scans may be useful in determining which children need early and more aggressive intervention for clinical sinusitis post-BMT.

Bismuth subgallate, an agent that initiates clotting via activation of factor XII, has been advocated for use in controlling bleeding during tonsillectomy and adenoidectomy. Direct aspiration of bismuth has produced pulmonary complications in laboratory animals, but no clinical correlation in humans has been previously described. We report 2 cases of bismuth aspiration that resulted in respiratory difficulty after tonsillectomy and adenoidectomy. Neither child's respiratory compromise required airway intubation. This report of pulmonary complications secondary to bismuth aspiration should alert surgeons to the potential for airway problems when using bismuth as a hemostatic agent for tonsillectomy and adenoidectomy.

Objective: To ascertain the present common causes of sensorineural hearing loss (SNHL) in children and compare them with those of previous reports., Design: A retrospective review of the medical records for all children with a diagnosis of SNHL seen from January 1, 1993, through September 30, 1996, at our institution., Setting: A tertiary care children's hospital., Patients: Three hundred one children, aged 1 week through 18 years, who presented for evaluation of SNHL., Results: Of the 301 children, 68.1% had a definite or probable cause of their SNHL identified; 18.9%, 1 or more possible causes; and 31.9%, no obvious cause. A family history of SNHL or prematurity and/or complicated perinatal course was found in 28.6% of patients. Named syndromes, multiple congenital anomalies, meningitis, or prenatal maternal factors, including maternal prenatal substance abuse, were present in another 38.5%. However, syndromes commonly reported to be associated with SNHL, such as Waardenburg syndrome, were seen in less than 1% of patients. The average age at diagnosis was 3.02 years for the bilateral moderate or worse SNHL; for unilateral SNHL, the average age was 3.97 years. The most useful diagnostic study was computed tomographic scanning., Conclusions: Sensorineural hearing loss is fairly common in children. Extensive workups, often without clear direction, should be reconsidered based on the children with SNHL who otolaryngologists are now seeing. Infant screening programs, although identifying many children earlier, will also provide the opportunity to fine-tune the evaluation (ie, cytomegalovirus titers and/or cultures at birth), increasing the diagnostic yield.

Cyclin D1 and cyclin G are essential regulatory factors in the progression of the cell cycle from G0 through G1 and S phase. Aberrations in expression of these cyclins may lead to dysregulated cellular proliferation that could result in neoplasia. Amplification and overexpression of cyclin D1 have been observed in many human cancers, whereas cyclin G is a new cyclin recently described in osteosarcoma cells. This study was performed to determine whether these cyclins were amplified in head and neck squamous cell carcinoma (HNSCC) tumors. Polymerase chain reaction of DNA extracted from 22 HNSCC primary tumors and three HNSCC cell lines did not reveal amplification of cyclin D1 in any of the tumor samples. Southern blot analysis identified amplification of cyclin D1 in a single tumor. Amplification of cyclin G was not observed in any of the tumors by Southern blot hybridization with a cyclin G probe. HNSCC cell lines transfected with antisense cyclin D1 were tested for cell proliferation by the incorporation of 3H-thymidine into cells grown in serum-free media. By 72 hours of incubation, there was a greater than 30% reduction in proliferation of cells transfected with antisense cyclin D1 as compared with non-transfected control cells. The results indicate that cyclin D1 may play an important role in the growth and proliferation of HNSCC cells.

Background: Recently, the p16/CDKN2/MTS1 gene in the 9p21-22 region has been offered as a candidate tumor suppressor gene. We examined the frequency of hemizygous and homozygous deletions of p16/CDKN2 in head and neck squamous cell carcinoma (HNSCC) using a quantitative polymerase chain reaction (PCR) method., Design: Twenty-one HNSCC and 12 corresponding normal DNA samples were examined for deletion of p16/ CDKN2 using PCR amplification and fluorescent quantification of DNA. All tumor and normal DNA samples were also amplified with fluorescein-labeled primers for a control DNA marker on chromosome 8p (D8S265). The ratios of the observed fluorescence of the p16/CDKN2 and 8p PCR products were compared., Setting and Participants: Patients with HNSCC scheduled to undergo surgical resection of their tumors were recruited. After the specimen was removed, a portion of the tissue was snap frozen for further DNA extraction., Results: Eight tumors (38%) had p16/CDKN2-D8S265 ratios of greater than 0.75; 8 tumors (38%), from 0.25 to 0.75; and 5 tumors (24%), of less than 0.25, the average ratio in this last group being 0.06., Conclusions: These ratios suggest a higher rate of homozygous deletion than previously reported and significant probable hemizygous deletion of the p16/CDKN2 gene in HNSCC.